N.H. Admin. Code § Ins 2201.04

Current through Register No. 45, November 7, 2024

Section Ins 2201.04 - Certificate of Authority

Ins 2201.04 Certificate of Authority.

(a) Any health maintenance organization seeking to do insurance business in this state shall complete and submit an original copy of the National Association of Insurance Commissioners (NAIC) Uniform Certificate of Authority Application (UCAA) as a health maintenance organization.

(b) The UCAA includes 3 applications, http://www.naic.org/industry_ucaa_corp_amend.html, available as noted in Appendix B:

(1) The Primary Application - UCAA Form 2P, revised 08/18/14, for use by newly formed companies seeking a Certificate of Authority in their domicile state and by companies wishing to re-domesticate to a uniform state;

(2) The Expansion Application - UCAA Form 2E, revised 08/18/14, for use by companies in good standing in their state of domicile that wish to expand their business into a uniform state; and

(3) The Corporate Amendments Application - UCAA Form 2C, revised 12/19/14, for use by an existing company for requesting amendments to its certificate of authority.

(c) The UCAA application shall be complete, provided, however, that where a form mentions perjury, perjury shall mean any applicable penalty found in RSA 641, falsification in official matters, including RSA 641:3, unsworn falsification.

(d) The UCAA application shall also include all required information and attachments, and shall include the following state specific information and requirements:

(1) If the applicant is not domiciled in this state, a power of attorney duly executed and appointing the commissioner and his successors in office, and duly authorized deputies, as true and lawful attorney for the applicant for service of process in this state pursuant to RSA 420-B:4;

(2) Payment by check or other draft of required application fees as set forth in RSA 400-A:29;

(3) Basic organizational documents, articles of incorporation, and all amendments thereto;

(4) Copies of all by-laws, rules, and regulations of the applicant;

(5) Copies of the organizational chart of the applicant, including the titles, names, and salaries, if any, of officers and key management personnel dealing in marketing, administration, enrollment, grievance procedures, quality assurance, contract negotiations, and financial matters;

(6) A list of members of the board of directors, or similar policymaking body of the applicant, with the name, principal occupation, and employer of each;

(7) A description of the applicant's proposed system for handling complaints that shall include procedures for the registration of complaints and procedures for the resolution of complaints;

(8) Financial reports for the prior 3 fiscal years, with the qualification that financial reports submitted by insurance companies or hospital, medical, or health service corporations applying for a certificate of authority to operate a health maintenance organization as a subsidiary or affiliate pursuant to RSA 420-B:19 shall be restricted in subject matter to the finances of such subsidiary or affiliate;

(9) Financial statements projecting the results of the applicant's operations for the next 3 years from the date of application, on a quarterly basis for years one and 2 and annually for year 3, including the following:

a. Balance sheet;

b. Statement of income from all sources, and expenses;

c. Cash flow;

d. Present and anticipated capital expenditures;

e. Repayment schedules for existing or anticipated loans or alternative financing arrangements;

f. Statement indicating when the applicant estimates that income from enrollments and other operations will equal expenses; and

g. Detailed statements underlying assumptions used and the basis thereof;

(10) A detailed statement of the health maintenance organization's plan to establish and maintain reserves or other funds necessary to cover any risks projected and not otherwise assumed by another entity, carrier, or reinsurer;

(11) A detailed statement of current and projected reserve-establishment calculations, as well as amounts, purpose and uses of the reserves, and assumptions and bases therefor, including, but not limited to, identification of reserves set aside to meet uncovered reinsurance items;

(12) Copies of all reinsurance, conversion, or other arrangements with other insurers, health providers, medical service corporations, hospital service corporations, health service corporations, governmental agencies or organizations, or other health maintenance organizations that provide payment schedules for contracted-for health care services, or made directly to provide services, in the event the health maintenance organization is unable or ceases to provide contracted-for health services for any reason;

(13) A copy of the applicant's official notification of status as a federally qualified health maintenance organization, if it is so designated;

(14) A statement of insurance or funded self-insurance for:

a. Protection against loss of property and liability of the applicant;

b. Workers' compensation to protect against claims arising from work-related injuries of the applicant's employees; and

c. Medical malpractice liability insurance for the applicant and its providers;

(15) A listing of shareholders or other equity holders, or members with holdings of 5 percent or more of capital shares, partnership interest, or other evidence of equity holdings, listed by name, address, number and percentage of shares or other interest held, and any other affiliations with the applicant;

(16) A listing of the applicant's legal, accounting, and actuarial representatives by name and address;

(17) A statement that fidelity bond coverage exists for all officers and employees entrusted with the handling of funds for the applicant;

(18) A statement of enrollment practices and procedures;

(19) An enrollment projection of members per month for the next 3 years from the date of application, on a quarterly basis for years one and 2, and annually for year 3, including:

a. The current total enrollment of the applicant;

b. The current categories of membership of the applicant:

1. Private;

2. Group;

3. Non-group;

4. Medicaid;

5. Medicare;

6. Federal employees;

7. State employees; and

c. A detailed statement of assumptions used, and the basis therefor;

(20) A description of the geographical area to be served, including:

a. Present population figures for each city or town within the current area; and

b. Projections of future population trends for each city and town within the current area for the next 5 years from the date of application; and

(21) A statement certifying to the commissioner that the health maintenance organization is in compliance with all federal laws and regulations pertaining to health maintenance organizations.

(e) The application documents shall be compiled in the order in which they are required.

(f) The applicant shall state the reasons for the absences of any items required, but not included in the application.

(g) In the event that the commissioner finds the application incomplete, the commissioner shall provide the applicant written notice specifying the additional documents or information required under this part.

(h) The applicant shall have 30 days from receipt of the notice in which to file the additional material required by (d) above or the application shall be deemed rejected.

(i) Prior to the issuance of a certificate of authority to operate a health maintenance organization, an applicant may:

(1) Engage in such activities as are necessary to the gathering of information for applications for certification as a federally qualified health maintenance organization, and for certification pursuant to RSA 420-B and these parts;

(2) Make contact with potential enrolled participants, employers, or both for the purposes of determining the feasibility of establishing a health maintenance organization in a given area, and for the purpose of generally acquainting the potential enrolled participants, employers, or both with the general benefits of the applicant's proposed program; and

(3) Engage in the establishment of physical facilities for the operation of the health maintenance organization.

(j) In no event, shall an applicant make a commitment to render services or initiate a contract between the applicant and enrolled participants, employers, or both until a certificate of authority has been issued by the department.

(k) The applicant company may continue to operate pursuant to Ins 2201.04(i), above, until such time as its application shall be denied.

(l) Before issuing a certificate of authority to an applicant, the commissioner shall be satisfied, by examination and evidence that the applicant has complied, and will continue to comply with the requirements of RSA 420-B and this part.

(m) The commissioner shall act upon an application for a certificate of authority within 90 days after the filing of a completed application.

(n) The commissioner shall notify the applicant, in writing, of the approval of the application or its denial, and if the application is denied, the reasons therefor.

(o) If the applicant wishes a hearing before the commissioner concerning the denial of the certificate of authority, it may make an application for such hearing pursuant to RSA 400-A:17 and the hearing shall be conducted in accordance with the provisions of RSA 400-A and Ins 200.

(p) Each certificate of authority issued under this part shall be renewed pursuant to RSA 420-B:5-a unless revoked or suspended by the commissioner, provided that the health maintenance organization commences operations within one year after the date on which the certificate of authority was issued.

(q) Failure to commence operations within the period in (p) above shall invalidate the certificate of authority and a new application shall be submitted before another certificate of authority will be issued.

(r) Grounds for revocation or suspension of certificate of authority shall include:

(1) An unsound financial condition;

(2) Business policies or methods are unsound or improper;

(3) Management conditions that render the further transaction of business hazardous to the public or to its members;

(4) The committing of acts prohibited by RSA 420-B:12; and

(5) Officers or agents that have refused to submit to an examination as provided for in RSA 420-B:10.

(s) Any denial or approval of the application shall be public, however, all documents and workpapers submitted or used in the course of analysis by the department of the financial condition of the applicant shall be confidential in accordance with RSA 400-A:37 and not subject to disclosure under RSA 91-A. Any other information submitted as part of the UCAA application by the health maintenance organization that is confidential commercial information, proprietary information, information protected as a trade secret, information that is confidential by law, or information that, if disclosed, would constitute an invasion of privacy shall be marked by the health maintenance organization as confidential and shall not be subject to disclosure under RSA 91-A.

N.H. Admin. Code § Ins 2201.04

#1900, eff 1-1-82; ss by #4287, eff 7-1-87; ss by #5655, eff 7-1-93; ss by #7018, INTERIM, eff 7-1-99, EXPIRED: 10-29-99

New. #9335, eff 12-5-08

Amended by Volume XXXVI Number 41, Filed October 13, 2016, Proposed by #11194, Effective 12/5/2016, Expires 12/5/2026.